Health in North Korea

North Korea has a life expectancy of 71.69 years as of 2016[update][1]. While North Korea is classified as a low-income country, the structure of North Korea's causes of death (2013) is unlike that of other low-income countries.[2] Instead, it is closer to the worldwide averages, with non-communicable diseases – such as cardiovascular disease – accounting for two-thirds of the total deaths.[2]

A 2013 study stated that the largest obstacle for understanding the accurate health status of North Korea is the lack of the validity and reliability of its health data.[2]

North Korean health services are offered for free.[4] In 2001 North Korea spent 3% of its gross domestic product on health care. Beginning in the 1950s, North Korea put great emphasis on healthcare, and between 1955 and 1986, the number of hospitals grew from 285 to 2,401, and the number of clinics – from 1,020 to 5,644.[5] Special health care is available mainly in cities,[6] where pharmacies are also common.[7] Essential medicines are well available.[8] There are hospitals attached to factories and mines.

Most hospitals that exist today were built in the 1960s and 1970s.[9] During the rule of Kim Il-sung, effective mandatory health checkups and immunization programs were initiated.[10] The country could support a large corps of doctors due to their low salaries. The number of doctors remains high, though there is a shortage of nurses, meaning that doctors often have to perform routine procedures. The medical infrastructure is fairly effective in preventative medicine, but less so in terms of treating the more demanding conditions.[11] Since 1979 more emphasis has been put on traditional Korean medicine, based on treatment with herbs and acupuncture A national telemedicine network was launched in 2010. It connects the Kim Man Yu Hospital in Pyongyang with 10 provincial medical facilities.[12]

North Korea's healthcare system suffered a steep decline since the 1990s because of natural disasters, economic problems, and food and energy shortages. By 2001, many hospitals and clinics in North Korea lacked essential medicines, equipment and running water due to the economic embargo and blockade by the United States and the international community.[13] Electricity shortages remain the biggest problem. Even if sophisticated equipment were available, they are rendered useless if electricity is not available. Some facilities have generators available to meet demand during power outages.[6]

In 2010, the World Health Organization (WHO) described the healthcare system as "the envy of the developing world" while acknowledging that "challenges remained, including poor infrastructure, a lack of equipment, malnutrition and a shortage of medicines." The WHO criticized an earlier Amnesty International report that described "barely functioning hospitals" as outdated and factually inaccurate.[14]

During the 1990s, North Korea was ravaged by famine, causing the death of between 500,000 and 3 million people.[3] Food shortages are ongoing today, with factors such as bad weather, lack of fertilizer and a drop in international donation meaning that North Koreans do not have enough to eat.[18] A study of North Koreans in 2008 found that three-quarters of respondents had reduced their food intake.[18] Extreme poverty is also a factor in the hunger faced by North Korean people, with 27% of the population living at or below the absolute poverty line of less than US $1 a day.[3]

These food shortages cause a number of malnutrition diseases. A 2009 UNICEF report found that North Korea was “one of 18 countries with the highest prevalence of stunting (moderate and severe) among children under 5 years old”.[18] A survey in 2017 found that less than 20% of North Korean children were stunted, a decrease from 32% in 2009.[19]

A survey conducted in 2017 found that most people had access to a toilet, but that 93% of sanitation facilities were not connected to a sewage system. Rather, the human waste was used as fertilizer on fields, creating the potential health risk of spreading intestinal worms. The survey also found that a quarter of people had contaminated drinking water.[20]

In 2006, Professor Gerd Auffarth of Heidelberg University Eye Hospital in Germany was permitted to visit the country. He is one of the few Western surgeons to have carried out eye surgery in North Korea. Before he arrived in Pyongyang, he was authorized to do just five surgeries but once he reached the University Hospital he found that he could do seventeen: one perforating keratoplasty using donor tissue he had brought from Germany, three scleral-fixated secondary IOL implantations, and thirteen phacoemulsification procedures with IOL implants. All the procedures were conducted with topical anaesthesia which had been brought from Germany. He reported on his experiences in 2011 in a video entitled, Ophthalmology Behind the Iron Curtain: Cataract Surgery in North Korea, saying that the economic conditions have led to improvisations - especially because of the absence of consumable medical devices but he commented that once a visiting surgeon adapts to these unique surroundings, he found that teaching and clinical work could be very effective and satisfying for both surgeon and patient.[21] As a consequence of this visit, in 2007 two young North Korean ophthalmic surgeons were permitted to visit Heidelberg and remain for six months, gaining extensive training in cataract surgery.

Non-communicable diseases risk factors in North Korea include high rates of urbanisation, an aging society, high rates of smoking and alcohol consumption amongst men.[2]

Approximately 54.8% of all North Korean adult males smoke an average of 15 cigarettes per day.[16] Smoking prevalence is slightly higher amongst the urban worker population than the farming population.[16] Amongst men, a high rate of excessive alcohol consumption has been reported, defined by the world health organisation as consumption of more than one bottle, per sitting, per person (26.3% of males)[16]

In the past, North Koreans did not have many problems with dental health because their diet did not include lots of sugars.[24] Since the 2000s, sugar has been introduced to diets in the form of candies and sweet snacks, especially in urban areas. Toothpaste is not regularly used.[25]

In 2010, Amnesty International reported that North Korea was experiencing a tuberculosisepidemic, with 5% of the population infected with the disease. It attributed this to the “overall deterioration in health and nutrition status of the population as well as the rundown of the public health services”.[18]

In 2010, infections that cause pneumonia and diarrhea were reported to be the leading causes of child death.[27] In 2009, one-third of the school-age children in North Korea were assessed as having diseases caused by intestinal parasites.[28]

The government has always maintained that North Korea is completely free of AIDS.[29][30][31] According to UNAIDS, less than 0.2% of North Korea's adult population had HIV in 2006.[32] In 2018, WHO's North Korean office said there were no reported HIV positive cases in the country.[33]

A study in 2002 found both men and women were reasonably educated about HIV/AIDS. More than two thirds knew about ways to avoid HIV/AIDS, and there were only few misconceptions.[34] However, according to the UN Population Fund in 2001, even hospital staff occasionally had limited awareness.[30] Travel across the border to China has been seen as a risk factor.[30][35]

In 2011, North Korea spent a million dollars on HIV prevention, with similar figures for previous years.[36] The same year, North Korea received 75,000 dollars of international aid for combating HIV/AIDS.[37] There are testing points and clinics,[30] but no antiretroviral therapy was reportedly available in 2006.[32]

North Korea has punitive laws concerning certain populations at risk of HIV/AIDS. According to UNAIDS, such laws can stigmatize those affected by HIV/AIDS and hinder their treatment. North Korea criminalizes the sex trade. Some drug related crimes are a capital offense. On the other hand, drug users are not subjected to compulsory detention. Sex between consenting adult males is not illegal.[38] North Korea deports visitors upon discovery of HIV status.[39]